Contact/Order Form/Information

800-752-5470
302-477-1351
Fax 302-477-1083

2409 Chatham Drive
Wilmington, DE. 19803

ORDER FORM / INFORMATION REQUEST FORM FOR THE SANI-MIST ^TM Dispenser & Athletes Foot Solution To place an order, just fill out, print and send or fax this form to 302-477-1083
Company Name, Attn., Billing Address: (must have billing address) Be sure to include street address and Zip.	Yes, I am interested, please call me at:
	Ask for (name):
Ship To*: Be sure to include street address and Zip.	Yes, I am interested, please send me more information to the address on the left.
	I am a distributor. Please send information to address at left.
	Bill Me. My P.O. # is:
Visa Exp. V-code ((must have: v-code is found on back of card))	Mastercard Exp. V-code ((must have: v-code is found on back of card))
Authorized Signature: (for mailed or faxed forms where credit card is indicated) _________________________________________
Please Send Me Dispensers @ $179.99 ea.	Subtotal $
Please send me cases of Sana-Mist ^TM solution @ $98.00 per case (4 gallons per case)	Subtotal $
Please send me cases of Athlex ^TM 4 oz. pump spray solution @ $83.76 per case: 24 bottles $3.49 ea.	TOTAL $
ASK ABOUT OUR QUANTITY DISCOUNTS *WE WILL ADD UPS CHARGES AND SALES TAX (IF APPLICABLE)
Send or Fax this form to: SANI-MIST, Ltd., 2409 Chatham Drive • Wilmington, DE. 19803 • Toll Free: 800-752-5470 • Phone: 302-477-1351 • Fax 302-477-1083
Distributors Welcome • Call or Fax for Information